The Health of Polish labour immigrants in Norway - Nakmi

Elżbieta Anna Czapka

The Health of Polish labour immigrants in Norway A Research Review

NAKMI report 3/2010 Norwegian Center for Minority Health Research (NAKMI)

Elżbieta Anna Czapka The Health of Polish labour immigrants in Norway: A Research Review

NAKMI report 3/2010 Author: Elżbieta Anna Czapka

© NAKMI – Norwegian Center for Minority Health Research NAKMI report (NAKMIs skriftserie for minoriteter og helse) Author: Elżbieta Anna Czapka Editor: Karin Harsløf Hjelde ISSN: 1503-1659 ISBN: 978-82-92564-10-3 Design and print: 07 Gruppen AS, 2010 Norwegian Centre for Minority Health Research (NAKMI) Oslo University Hospital, Ullevål Hospital P O Box 4956 Nydalen NO-0424 Oslo Norway [email protected] www.nakmi.no

Contents Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Polish labour immigrants in Norway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Research methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Immigrants’ self-evaluation of health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Immigrants’ use of health care services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Immigrants’ lifestyle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Health-related moral code. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 An introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1. Polish people in Norway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.1. Historical background in brief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.2. Contemporary Polish immigration – official statistics and unofficial estimates . . . . 9 1.3. Poles on the Norwegian job market. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2. Migration and health – the theoretical basis for the research. . . . . . . . . . . . . . . . . . . . . 11 3. Research methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3.1. Problems and research hypotheses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3.2. Research methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.3. Research sample characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4. Immigrants’ health self-evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.1. Declared changes in the state of health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.2. Immigrants’ mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.3. Immigrants’ social relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.4. Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 5. Immigrants’ use of the health care services in Norway. . . . . . . . . . . . . . . . . . . . . . . . . . 25 5.1. Use of health care services in Poland and in Norway . . . . . . . . . . . . . . . . . . . . . . . 25 5.2. Obstacles limiting access to the health care services in Norway . . . . . . . . . . . . . . . 27 5.3. Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 6. Immigrants’ lifestyle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 6.1. Housing conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 6.2. Eating habits and nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 6.3. Use of addictive substances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 6.4. Sex life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 6.5. Leisure and sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 6.6. Physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 6.7. Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 7. Health-related moral code of the Polish immigrants. . . . . . . . . . . . . . . . . . . . . . . . . . . 38 7.1. Health care as a duty according to the immigrants . . . . . . . . . . . . . . . . . . . . . . . . . 38 7.2. Health as a value . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

The Health of Polish labour immigrants in Nor way

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7.3. Health-related convictions and behavioural patterns according to the Polish immigrants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4. Readiness to sacrifice as declared by the immigrants. . . . . . . . . . . . . . . . . . . . . . . 7.5. Sanctions experienced in the case of putting health at risk under specific circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6. Implications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Final conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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NAKMI repor t 3/2010

40 42 44 46 48 49 51 76

Acknowledgements I would like to express my warmest gratitude to Professor Nora Alhberg who enabled me to carry out this research as part of my post doc project at the Norwegian Centre for Minority Health Research. I would also like to thank my colleagues at NAKMI for their invaluable help and enriching discussions. Among those who deserve special thanks are Karin Harsløf Hjelde, Arild Aambø and Vera Minja, who offered endless patient support during my time at NAKMI. My thanks for creating a friendly atmosphere and providing great encouragement go to Thor Indseth, Claire Mock Munoz de Luna, Emine Kale, Jennifer Gerwing, Ragnhild Spilker, Torunn Arnsten Sajjad, Ursula Goth and Sara Kahsay. The research would not have happened had it not been for my respondents who devoted their time to filling in the questionnaires and answering my interview questions. Thank you to all. Last but not least, I owe a debt of heartfelt gratitude to Professor Zofia KawczynskaButrym, who was a constant source of support at all stages of the research. NAKMI, September 2010 Elżbieta Czapka


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Summary Polish labour immigrants in Norway Since Poland joined the European Union in 2004 and several job markets in Western Europe became accessible, great numbers of Poles have emigrated in search for work and higher income. Norway has become a popular destination for the Polish immigrants due to its demand for workforce. In Norway Polish men work mainly as construction workers, which involves a specific risk to their health. Women, on the other hand, are mostly employed as house cleaners, child minders or social care workers. They are often employed illegally without being officially registered, which leaves them with no access to social welfare benefits or health care services.

Research methods The research is both qualitative and quantitative in nature. The data were gathered by means of a questionnaire survey consisting of 83 general questions and 14 factual profile questions. Additionally, ten individual interviews were conducted and five focus interviews were held in order to gain a deeper insight into a number of research issues. Since snowball sampling was employed as the method, the research results are in no way representative of the entire population of Polish immigrants in Norway. The report also uses data from several representatives of Norwegian institutions, collected during information meetings which were organized for the Polish people by Jerzy Gruca, a member of The Polish Club, and the report’s author.

Immigrants’ self-evaluation of health Migration is not only connected with changing your position geographically but it also involves a shift in position within the social structure. Existing research has proven that shifts in an individual’s social status are reflected in changes of their health. The research in question analyses health in its three dimensions: biological, mental and social. The Polish labour immigrants in Norway assess their health in a relatively positive way. 46 % admitted that certain changes in their health had occurred, of which 26 % described those changes as not beneficial. Most frequently the immigrants mentioned a feeling of fatigue and insomnia. Regarding their mental health, they declared that a good emotional state was experienced more often in Poland than in Norway. This is attributed to their social isolation, an evident feature of the Polish immigrants’ participation in social interaction. For a number of reasons the Polish people fail to integrate with the Norwegian community.

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Immigrants’ use of health care services As declared by the immigrants, their access to the health care services was limited due to their incompetence in the use of the Norwegian language and insufficient information about the health care system. The immigrants admitted to using health care services in Poland more frequently than in Norway. Their future plans had a significant impact on the way they used the Norwegian health care system. People who intended to settle down in Norway were more eager to take advantage of the medical care available in Norway.

Immigrants’ lifestyle The lifestyle of the Polish immigrants in Norway differed significantly from their lifestyle in the native country. The changes are particularly visible in the initial stage of their life in the foreign country. That is when the immigrants tend to save money by cutting down on food, which consequently influences their health. The research results show that the most evident changes can be perceived when it comes to eating habits and nutrition, sex life and alcohol abuse. This may be due to the fact that the immigrants seem to experience no social sanctions as a result of breaching certain moral norms which were part of the moral code that they used to observe in Poland.

Health-related moral code The most vital value for the immigrants is their family. They are prepared to put their health at risk for the sake of the family. As declared by the respondents, they would not experience any negative internal sanctions (guilt, shame) or external sanctions (contempt) if they consciously risked their health in order to help their families. The vast majority of immigrants admitted that tending to one’s own health is a moral duty of each individual. Their main motives include their family’s well-being and caring for their health, which is considered to be a gift from God. Implications The results of the research show that lack of knowledge of the Norwegian and/ or English language is one of the most significant factors influencing the immigrants’ health. Their communicative competence affects the immigrants’ access to the health services as well as their participation in social relations. Furthermore, the immigrants are prepared to sacrifice their health for the sake of the family, which ranks the highest in their hierarchy of values. This has some specific implications on the lifestyle of Polish migrants living abroad. They lead frugal lives and buy the cheapest food products available so that they can send a significant part of their income home to Poland. One way to improve the health of the Polish labour immigrants in Norway would be to take all of the necessary steps to encourage them to learn Norwegian or English. Besides that, it would be beneficial – both to the Norwegian state and the Polish immigrant community – if the immigrants were able to bring their families to stay with them in Norway.


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An introduction Europe is undergoing constant changes in the areas of culture and politics. The rapid pace of these changes has resulted in endless metamorphoses of Europeans’ daily lives ( Janicki, 2009). Migration can be regarded as both a reason and a consequence of such changes. It is unquestionable that for economic reasons Europe needs migrants. Moreover, most of the contemporary immigrants are labour migrants (Padilla, Pereira, 2007). New labour migration is a very specific phenomenon, because unlike before it is now much easier for migrants to move back and forth and keep in touch with their relatives back at home, even if they are on the other side of the globe. Norway became a destination for labour migrants in 1967 when the first group of Pakistani migrants came to Norway to find work in the oil industry (SSB, 2009). Since the European Union’s extensive development Norway has been attracting more and more labour migrants from the EU 8 every year (SSB, 2009), especially from Poland. According to estimates, about 2 million people left Poland, an ex-communist state, after joining the European Union in 2004, seeking better lives and wages in richer Western EU member states. Most of those who left were young people complaining about poor career prospects in Poland, which was battling unemployment levels of about 20 per cent and a worryingly slow economic growth. New labour immigrants from the EU 8 work mostly as construction workers and they are exposed to work-related accidents.

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1. Polish people in Norway 1.1.

Historical background in brief

Poles arrived in Norway for the first time during World War II. They had been sent there to do compulsory work, mainly road and airport building. Some of them decided to stay and built the foundation for the Polish community in Norway. The second wave of Polish immigrants arrived in the 1980s when the political activists of the Independent and SelfGoverning Trade Union „Solidarnosc” were accepted as asylum seekers and given residence permit by the Norwegian authorities (Olszewski, 1997). Owing to the fact that immigration networks had already been established, the 1990s Polish immigration was made relatively easier. Undeniably, the breakthrough moment for Polish migration to Norway was when Poland became an EU member state in 2004.

1.2.

Contemporary Polish immigration – official statistics and unofficial estimates

According to the official data published by the Statistics Norway on 1 January 2010, there are 52,125 immigrants from Poland residing in Norway (SSB, 2010). It is a labour migration in nature1. Despite the economic recession, which consequences were to some extent experienced in Norway as well, the country has remained an attractive destination for the Polish immigrants. In 2009 3,618 immigrants left Norway, but as many as 10,511 new immigrants seeking employment and new sources of income arrived in the country. Only 5,074 Poles (9.7 % of the entire Polish population) have obtained a Norwegian citizenship. In 2007 most Polish immigrants resided in Oslo (6,581), Bergen (2,022), Bærum (1,442) and Stavanger (1,272). 93 per cent of Poles who immigrated in order to seek labour were men, while 56 per cent of those who immigrated as family immigrants were women. The Polish population in Norway is highly diversified as far as the length of their stay abroad is concerned: 25 years and more (since 1984) – 1603 20-24 years (1985-1989) – 1361 15-19 years (1990-1994) – 1141 10-14 years (1995-1999) – 847 5-9 years (2000-2004) – 2558 0 – 4 (2005-2009) – 41,799 The data quoted above show a considerable increase in the immigrant mobility between Poland and Norway since 2004. Compared with the period preceding Poland’s EU membership, there are over four times more Polish immigrants with a work permit. Undoubtedly, the most important factor which 1 In the period between 1990 and 2008 in Norway there were 44,617 Poles, out of which 31,923 were labour immigrants. In 2008 14,116 more immigrants arrived, including 10,401 labour immigrants.


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attracts immigrants to Norway is the country’s considerable demand for foreign workforce and far higher wages offered to employees than those available in Mid-Eastern European countries. Even though Norway is not a member of the EU, the country has incorporated several EU legal regulations concerning the job market and social welfare benefits. Another factor which attracts the immigrants is the existence of employment and recruitment agencies. They act as in-betweens in arranging employment but also provide some sort of accommodation. Poles are willing to work in Norway as a consequence of the unsatisfactory situation on the Polish job market and relatively low wages. It must be mentioned that since 1 October 2009 the Polish citizens are not required to apply for permission to stay and work in Norway (UDI, 28.12.2009). They are allowed to reside in Norway for three months without registration but are then required to register at the police. Once they become employed, they should register immediately. Those actively looking for work in Norway are also supposed to register. The registration in question is made for an infinite period of time. It is impossible to establish the exact number of Polish immigrants in Norway because many Poles do not possess ID numbers and, consequently, work illegally. In particular, this is the case with female house cleaners. Thus, these have no rights to health care services, except for emergency services, a fact which seems to be somehow tolerated by both Norwegian employers and Polish immigrants. As Okolski claims, “there are no bases, apart from the intuition and bravery of some experts, to assess the dynamics of the illegal migrants” (Okolski, 2004). Hence, the author will abstain from quoting any numerical data to estimate the number of Polish illegal workers in Norway.

1.3.

Poles on the Norwegian job market

In countries where immigrants are employed on a large scale, they are overrepresented in the field of services, mainly in the hotel and catering industries as well as housekeeping and construction. As a matter of fact, this sort of overrepresentation is not encountered in the field of administrative clerical professions and tends to be quite rare as regards education and agriculture. (Okolski, 2004). The IMDI Research shows that more than eight out of ten people arrived in Norway to work (IMDI, 2008). Nearly 70 per cent of the Polish labour immigrants work as artisans. Over 50 per cent of men and almost 40 per cent of women claim that their profession corresponds to their qualifications and skills, which links directly to the Polish immigrants’ educational background. According to the IMDI research, as many as 79 per cent of the immigrants claim to have completed a vocational school or training and hold the necessary qualifications. More than a third of the Polish workers state that they have received lower wages than Norwegians employed to perform the same duties or hold the same post. This reveals that the Polish people feel that they are treated unfairly on the job market in comparison to the workers from the Baltic countries.

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2. Migration and health – the theoretical basis for the research A huge body of research has documented that there is a strong relation between health and migration. However, there is no direct link between these two phenomena. Migration in the geographical space tends to be related to vertical mobility and leads to changes in the social status of an individual. More frequently it boils down to social degrading than to social advancement. As Nazroo highlighted, the social position is a very important factor in determining the health of migrants (Nazroo, 1998). Changes in health reflect the changes in the social position of the individual, which confirms the thesis that migration influences the social position of migrants. However, some researchers claim that ethnic inequalities in health are not related to socioeconomic inequalities (Wild, McKeigue, 1997), while others claim that it is necessary to consider factors such as culture, socioeconomic status and genetic characteristics in order to explain ethnic inequalities in health (Smaje, 1996). Usually people who go abroad for economic reasons are quite healthy. This phenomenon is well known as the healthy migrant effect. Migrants are convinced that they will be able to cope with the new reality and adapt to the new circumstances. They assess their health capital positively as it enables them to work hard and, as a result, improves their economical situation. However, migrants are unable to predict all the obstacles they can encounter abroad even if they do have some worries2. According to some research results, new labour migrants feel healthy before going abroad but state that their health deteriorates during their stay abroad. When they retrun home they assess their health as better than it used to be during their stay abroad but worse than before leaving the country (Kawczynska – Butrym, 2008). The changes in health may result from lower self-esteem and social degradation experienced by a migrant in a foreign country, especially when their work is of a lower status in the professional hierarchy and offers worse career prospects than the job they used to do back home. New labour migrants are mostly employed in the service sector, and some jobs, especially construction work, involve a high risk of accidents and permanent health damages. The kind of job being done is a very important factor influencing male migrants’ health in its three dimensions: social, mental and physical. Considering health issues, labour migrants, especially unregistered ones, constitute a particularly vulnerable group. Limited access to the health care services for immigrants has attracted researchers’ attention recently. Despite the right to use the health care services, immigrants encounter obstacles such as limited access to information, language incompetence, economic barriers, and cultural barriers which make it 2 According to Kawczynska’s research results, young Polish migrants in Ireland and Great Britain had some worries concerning emigration but still, they decided to leave Poland. They were afraid of: family longing –63,3 %, speaking a different language –52,2 %, financial problems –34,4 %, difficulties with finding a job –67,8 %, failures at work –31,1 %, different customs – 15,6 %.


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either difficult or impossible to take advantage of the health services in the destination country. In contemporary society, information becomes a type of immaterial good, which is sometimes much more valuable than material goods. Accordingly, a lack of information can marginalize particular social groups. All people have equal rights to obtain the necessary information because the state authorities are obliged to use resources to ensure equality in social, cultural, political and economical spheres between the minority and the majority groups. In the age of globalization, the state still plays an important political role. Unfortunately, many governments have difficulties “to construct new forms of interaction with their citizens” (May, 2002) and instead rely on existing communication channels. Migrants have the right to know what kind of medical help they are entitled to, what health care services are available and how to get the required help. However, it seems as if migrants and ethnic minorities with low education become increasingly disadvantaged and marginalized in the information/network society. Many have insufficient digital skills and lack dominant language competence. If nothing is changed “ethnic minorities will undoubtedly be among “the misfits” of the network society in both work and in social communications” (Van Dijk, 2006). Undoubtedly, advances in information and communication technologies somehow influence the type of information people have access to and the sources of the information (Dutton et al. 2006).

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3. Research methodology 3.1.

Problems and research hypotheses

The main aim of the study is to investigate whether the Polish labour migrants have experienced changes in their state of health since their arrival in Norway (according to their declarations) and to discover the main obstacles to using the health care services in Norway. Methodologically, it seems reasonable to compare the declarations concerning the immigrants’ state of health before arrival in Norway with those during the period of time spent in the foreign country. If the aim is representative research, it would be useful to analyse the health condition of the Polish immigrants in comparison to their compatriots living in their native land. However, this objective cannot be reached in the case of the author’s research. Moreover, due to the cultural, environmental and economical differences, I do not consider the comparison of the Polish immigrants and the Norwegian society as regards their health state to be scientifically justified. The following research questions were formulated: 1. How do the Polish migrants assess their health state with regard to any changes experienced after their arrival in Norway? What is the immigrants’ health (social health, in particular) like, on the basis of their declarations? 2. Do they declare any lifestyle changes (eating habits, leisure and sleep, sex life, physical activity, use of addictive substances) to have occurred? 3. Do they use the health care services in Norway or in Poland? What are the reasons behind using or avoiding the health care facilities abroad? What kind of obstacles did they experience when using the health care services abroad? 4. How does their health rank in the immigrants’ hierarchy of values? Are there any circumstances under which the migrants would be prone to put their health at risk? Would that result in experiencing specific sanctions – both internal and external? 5. What socio-demographic factors have influenced the immigrants’ declarations? In reply to the research problems posed above, the following hypotheses were formulated: 1. Migrants declare that the state of their health is worse in Norway than it used to be in Poland. 2. They declare that their lifestyle has changed since their arrival in Norway. 3. They use the health care services mostly in Poland. The main reason is lack of information about the Norwegian health care system and language incompetence. 4. Their health ranks low in the migrants’ hierarchy of values. The migrants will be prone to put their health at risk for the sake of their families and faith in God. In consequence, they will experience no external and internal sanctions.


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5. The migrants’ declarations concerning the state of their health vary depending on their age, gender, educational background, religion and occupation in Norway as well as the length of residence in Norway, their linguistic competence (knowledge and usage of the Norwegian language), their plans to stay in or leave Norway and the purpose of their emigration.

3.2.

Research methods

The character and the specificity of the research required both quantitative (survey) and qualitative (semi-structured individual interviews, focus group interviews, observation) research methods to be employed in order to answer the research questions. The research was carried out in three stages: a) A pilot study The aim of the pilot study was to test the design and quality of the questionnaire. The survey was divided into five parts according to the research problems in question. It contained 76 close-ended and half–ended questions and 14 factual questions. There were a few filter questions that preceded the contingency ones. The questionnaire was distributed among 20 immigrants who were requested to fill it in and include their comments concerning the research tool. b) Full-scale quantitative study Prior to the full-scale quantitative study, the questionnaire underwent corrections and modifications in response to the findings of the pilot study. Snowball sampling was chosen and, consequently, it is not representative of the whole population of young Polish labour immigrants in Norway. Any generalizations occurring in this study refer exclusively to the researched sample. It was impossible to use random sampling because the number of unregistered immigrants is impossible to specify and the existing registers are thus incomplete. To ensure that the sample has certain parameters relevant to the researched population, the respondents from diversified backgrounds were recruited from a variety of places and surroundings (building sites, churches, language schools, a Polish association in Norway). The immigrants were given the questionnaires together with addressed and stamped envelopes. They were asked to distribute them among their friends and relatives, fill them out and return by mail. This procedure was to guarantee the anonymity of the research. Eventually, several questionnaires had to be rejected because a number of replies were missing, especially in the factual part including the personal profile data. Some information used in the report was also collected during the information meetings for the Polish immigrants with representatives of The Service Centre for Foreign Workers. The meetings were organised by Jerzy Gruca, a representative of the Polish Club and the report`s author. Among the issues raised during those meetings were the problem of information deficiency among the immigrants in Norway and the barriers which limit access to the necessary information.

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c) Complementary qualitative study The semi-structured individual interviews and the focus group interviews were conducted to get a deeper insight into some research issues and investigate the ones that could not be explored by means of a survey. At this stage the informants were recruited with regard to some specific characteristics, such as educational background, occupation and length of stay in Norway. As a deputy leader of one of the Polish associations in Norway, the author was an active participant of the Polish immigrant community life in Oslo, which enabled her to observe the immigrants’ lifestyle in a participatory manner. The research was conducted between 2008 and 2009.

3.3.

Research sample characteristics

The questionnaire survey was filled in by 107 Polish labour immigrants in Oslo, and 32 immigrants participated in the interviews. The majority of informants were male (58 %). The group was differentiated with respect to age (17-25: 20 %, 26-30: 34 %, 31-40: 18 %, 41-50: 16 %, over 50: 7 %)3, educational background (vocational education: 24 %, general secondary: 31 %, tertiary (BA): 17 %, tertiary (MA, PhD): 28 %) and length of stay in Norway (5-6 months: 21 %, 7-12 months: 22 %, 13-24 months 22 %, more than two years: 35 %4). 40 % of the surveyed immigrants came to Norway alone without any friends or relatives. Only 21 % of the immigrants arrived in Norway accompanied by their spouse, 20 % came with their partner and 11 % with their offspring. The reasons for coming to Norway varied5: • their own financial difficulties – 28 %, • their parents’ financial difficulties – 3 %, • their need to earn money with a particular aim in mind, such as providing for their children in the future, buying a car, organizing a wedding, buying a flat, working in order to obtain retirement benefits in the future, reuniting with a partner, having a nomadic lifestyle, language learning, having no prospects for the future in the native country – 34 %, • difficulty of finding a satisfying job in the native country – 17 %, • difficulty of finding any job in the native country – 3 %, • attempt to gain new qualifications – 19 %, • undertaking studies – 4 %, • getting married – 9 %. It must be added that as many as 50 % of the immigrants mentioned the people who depend on them financially6: spouse – 32 %, partner – 5 %, child(ren) – 22 %, parent(s) – 6 %, sibling(s) – 2 %. 3 4 5 6

5 % refused to answer the question about age 2 % didn’t answer that question Informants could point to more than one answer Informants could point to more than one answer


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For 85 % of the immigrants who took part in the research, their stay in Norway was connected with legal employment (11 %: illegal work, 38 %: learning Norwegian, 7 % visiting family, 7 %: exploring Norway)7. 34 % decided to stay in Norway; 40 % wanted to return to Poland after some time (the date was not specified at that point) and 26 % definitely wanted to go back. It often happened that people went abroad to work with an intention to stay for a few months and then prolonged their stay for undefined stretches of time.

7 Informants could point to more than one answer

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4. Immigrants’ health self-evaluation Long-term stay abroad influences our general well-being and mental activity. As a result of experiencing a variety of difficulties and failures in a new environment, negative emotions may accumulate and difficulties in solving problems successfully tend to generate frustration. Physical exhaustion and a long-lasting exposure to stress overburden the nervous system and decrease our mental immunity. Kawczynska-Butrym’s research, conducted in 2010 as part of a return migrants project, shows that health was the only one, out of 14 categories, which was described as deteriorating rather than improving. One in seven return migrants admitted a decline in their state of health8. In order to examine if migration had an impact on the state of health of the Polish immigrants in Oslo, they were requested to compare their health condition during their stay abroad and prior to their arrival in Norway.

4.1.

Declared changes in the state of health

Not surprisingly, most immigrants assessed their health condition as very good (30 %) and good (49 %). Only 17 % declared that their health was satisfactory and 4 % defined it as bad or very bad. It was important to ask the immigrants whether their health had undergone changes since their arrival in Norway. It appeared that the health of 54 % had not changed. 20 % admitted that their health had improved and 26 % reported deterioration in their health (table 1). Table 1. Changes in the state of health, as declared by the immigrants Health components

Health improvement

Health deterioration

Physical

Generally I am feeling better, I have better blood circulation, I spend more time outdoors (in the fresh air), I am not sick, I feel less pain in my back, I like the Norwegian climate, I have no problems with gastritis any more.

Accidents at work, permanent infections, diabetes, problems with my spine!!!, a pain in the legs, I am not fit enough, fatigue, tiredness, lack of energy, digestion problems, genital system problems, skin and nail problems

Mental

My mental health has improved because now I know that my family has everything they need except for the father and the husband, I am not stressed about providing for my family, I am in a better mood, experiencing lack of stress, no worries, a kind of stability, I am happy in my private life

stress!!!, family longing, working abroad demands more concentration and effort, bad mental condition, the weather affects me

Social

Nice work, new friends and new experiences, I work less than in Poland, the working conditions are better, I earn 8 times more than in Poland

Working in a specific environment (in the office), lack of friends

8 The text is in the process of editing before going to print.


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What is interesting, such variables as age, gender and length of stay in Norway did not differ among the immigrants’ declarations with regard to their health change. In order to learn what the informants meant by the health change, they were asked to point out what health problems they experienced more often in Norway than in Poland (Table 2). Table 2. Health problems experienced by the Polish immigrants` when abroad and in their native land (%) Experienced, but only briefly, right after my arrival

Experienced less than in Poland

Experienced more than in Poland

Did not experience at all

Experienced in the same way as in Poland

Stomachache

4

5

5

60

26

Headache and dizziness

4

8

14

51

23

Fatigue

7

4

25

36

28

Frequent infections

2

9

10

60

19

Insomnia

6

1

10

63

20

Excessive sleepiness

3

1

14

65

17

Allergies

4

7

12

65

12

Back pains

5

6

16

51

22

Other

4

-

8

88

-

Health problems

Very few immigrants stated that they had experienced the above-mentioned conditions in Norway less frequently than in Poland. Fatigue seems to be the biggest challenge. In Norway one in four informants experiences fatigue more frequently than they did in Poland. At this point it is worth emphasizing the results of the research carried out by Kawczynska-Butrym among return migrants in 2007 and 2008. The return migrants were asked about the occurrence of specific ailments, taking into account the periods before they left the native country, during their stay abroad and upon their return. According to declarations, their state of health deteriorated during the stay abroad, except for diarrhoea and apathy. The return migrants claimed that they experienced far more frequent psychosomatic symptoms (fatigue, irritation, insomnia) as well as back pain and muscle pain during their stay abroad. The latter could have been a result from the effort they put in while doing highly demanding physical jobs. Most frequently, as declared by the return migrants, their health improved slightly on their return home but still it was regarded as worse than before they left the country (Kawczynska-Butrym, 2008).

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4.2.

Immigrants’ mental health

The research conducted so far points to the fact that migration has an impact on the individual’s state of health. (Peters, 1986; Bruijnzeels, 2004). The majority of migrants who took part in the research claimed that they found themselves in a good emotional state, both in Poland and in Norway (table 3). However, the informants declared to be in a very good emotional state while in Poland, more frequently than in Norway. Table 3. Emotional well-being of the informants as experienced in Poland and Norway, according to their declarations (%) Categories

Poland

Norway

Very good

20

10

Good

50

53

Average

20

26

Poor

6

5

Very poor

1

2

Difficult to say

3

4

In order to obtain more detailed information about their mental state, the informants were asked about the kinds of emotions they experienced while in Norway and their frequency. (table 4). Table 4. Emotional states experienced by the immigrants during their stay in Norway, according to their declarations (%) Emotions

Yes

No

Difficult to say

Only at the beginning

Seldom

Frequently

Anger

14

34

12

34

6

Irritation

5

38

15

32

8

Nervousness

6

46

14

22

12

Helplessness

11

32

8

37

12

Indifference

4

26

11

46

13

Low self-esteem

9

21

10

52

8

Mood swings

5

24

18

39

14

Overwhelming homesickness

13

17

29

32

9

Depression

6

17

7

61

9

Happiness

4

23

31

24

18


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The immigrants often mentioned a feeling of overwhelming homesickness while 32 % did not experience it at any point during their stay in Norway. Nearly a third mentioned a frequent sensation of happiness. Among other frequently experienced emotions mentioned in the questionnaires were irritation, nervousness and mood swings. Living as an immigrant is to some extent a crisis situation. All the definitions of crisis emphasize that it is necessary for an individual to adapt to a new situation, which requires an efficient coping strategy. (Czapka, 2001). The comparison of coping strategies used by the immigrants in Poland and in Norway proved interesting. (table 5). Table 5. Immigrants’ coping strategies employed in Poland and in Norway (%) Strategies

Poland

Norway

Waiting for the problem to be solved, trying to survive

28

30

Talking to friends, asking them for advice

53

47

Eating sweets or other comfort foods

10

12

Seeking a psychologist’s help

4

2

Trying to sleep a lot in order to forget about things

6

9

Drinking alcohol in order to forget about sorrows at least for a while

5

4

Talking to relatives and asking them for help

40

32

Crying out of helplessness

8

15

Turning to a priest for help

3

3

Praying

36

36

Table 5 shows that, according to their declarations, while in Poland, the immigrants took advantage of such external coping strategies as talking to relatives, friends or a psychologist, slightly more often than in Norway. This is due to the fact that they have a more extensive network of family and social relations in Poland than in Norway. It must be mentioned that in Poland a family is the most important source of emotional support for its members and hence in an emergency situation people turn to their family for help. As many as seven per cent more admitted that they cry out of helplessness in Norway than they used to in Poland. Quite importantly, the immigrants turn to the most dysfunctional coping strategies (waiting for the problem to disappear, overeating, escaping problems by excessive sleeping) only a bit more frequently than they would in Poland.

4.3. Immigrants’ social relations According to the WHO definition of health, one of the criteria used to measure health is an individual’s participation in social relations. For the labour migrants residing abroad, incomeproviding work is the most important area of their social activity. It is of significance how the immigrants evaluate the work they do in Norway (table 6).

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Table 6. Evaluation of the work done in Norway, as declared by the Polish immigrants. (%) Fully

Partly

Not at all

Below expectations/ possibilities

No reply

Financially satisfying

27

56

2

9

6

Relevant to my qualifications

33

22

31

5

9

Health-friendly

24

30

33

4

9

Providing me with a sense of security

29

45

12

5

9

Providing me with a sense of respect

37

33

16

4

10

Providing me with promotion prospects on return to Poland

18

16

47

6

13

Providing me with promotion prospects here in Norway

20

27

38

4

11

Evaluation of work

The way the immigrants assessed the jobs done abroad varied. A third of them described the work they do abroad as not health-friendly. This was further confirmed in the interviewees’ comments: „Well, my health has deteriorated a tad because of the work I did for one of the companies. I won`t be mentioning its name. I did a lot of demolishing of plenty of concrete blocks, knocking down walls and what not. I have a bad back these days, because it is hard work.”(A.); „I could have ended up in this warehouse at minus 25 degrees centigrade but I had a feeling there was something wrong with it and I gave it up, especially since my mate wanted the job. Then Pawełek suffered from a testicle inflammation and a fever of 40 degrees. My mates who still work there keep complaining about kidney pain.”(D.). The interviewees tried to explain why their work often involves putting their health at risk: ”P1: When I first came here I sat at home for three months. You know, this sort of accommodating to Norway. And I realised it is not natural to work so f...ing hard, work non stop. It just ruins your health. P2: But there`s no choice. P3: We have to reach a certain status, minimal security, feel relaxed to some extent. P1: But the more you get, the more you want and this is the problem. The more money you earn, the more you expect. P3: But at a certain age you can’t do so much any longer. You come to realise that you can’t work that hard anymore. P1: Some of us reach this conclusion a bit earlier, others need more time. Personally, I guess I have realised I`m overdoing it a bit and that you mustn`t do that.“ The immigrants who filled out the questionnaires believed that their work did not guarantee future promotion prospects, neither in Norway (38 %) nor – even more so – in Poland (47 %). That confirms the thesis that the immigrants tend to do the jobs which are not


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eagerly taken on by Norwegians but are also considered less prestigious in Poland. In literature they tend to be referred to as 3D jobs (dirty, dangerous and dull) (Favell, 2008). The Polish immigrants do not participate actively in social relations. One piece of evidence is the fact that very few of them are involved in or interested in joining any association or organisation (table 7). Table 7. Participation in organisations and associations, as declared by the immigrants (%). Organisation/association

Yes

No

No, but I`d like to.

No reply

Church groups

15

60

3

22

Choir or music band

4

70

4

22

Sports club

10

53

16

21

Hobby club

5

62

10

23

Political party

3

72

2

23

Youth organisation

3

68

5

24

Polish association in Norway

12

57

12

19

Trade unions

17

55

6

22

Language school

44

34

11

11

Voluntary organisations

8

64

5

23

Such a low social activity may result from lack of time. Attending classes at a language school or joining trade unions are obviously highly instrumental in nature and as such more of a personal investment rather than a way of spending leisure time. According to their declarations, as many as 80 % of the immigrants spend their leisure time in the exclusive company of other Poles. Simultaneously, 31 % spend their spare time with Norwegians and 18 % favour the company of other nationalities. Apparently, the most significant barrier is the language gap. A fraction of the immigrants speak neither English nor Norwegian. As a result, they find it very challenging if not impossible to integrate with the Norwegian community: „Not until free lessons are available, will the Polish community cease to be pushed to the margin. Until then, we won`t blend with the Norwegian community, actually, standing no chance of doing that. ”(K.) The immigrants also mentioned other barriers they encounter in relations with Norwegians: „If we want to understand each other, ourselves and Norwegians, there is one solution I can see: Poles would need to be more in control of themselves and Norwegians would have to drink some alcohol to feel more relaxed, and then there is a chance.“(K.) “We don`t really hang out with Norwegians because they keep us at bay, being far from friendship, from social life – as far as Poles are concerned. I mean, they prefer their own company. But they are

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in such a good financial situation, so secure that they don`t tend to get in touch. As for the neighbours, they don`t keep in touch with you too much either.”(Krz.) Both the quantitative and the qualitative research show that the Polish live in a certain diaspora in Norway despite the fact that the Norwegian authorities make efforts to integrate new immigrants with the local community. Most immigrants who participated in the research and the Polish community activists maintained that the best solution would be Norwegian language courses available to participants free of charge. To establish what kind of relations exist between Poles and Norwegians, the informants were asked how often they interacted with Norwegians in specific places and situations (table 8). Table 8. Frequency of contacts with Norwegians in specific places and situations (%)9 Situations/places

Frequency of contacts Frequently

seldom

never

Offices and institutions

43

51

6

Shops

92

7

1

Church

20

38

42

Health care

21

45

34

Work

82

11

7

Social contacts (after-work meetings, cinema-going)

21

48

33

Neighbourhood

36

50

14

Closer friendship

13

32

55

The immigrants were also asked to specify – on a scale from 1 to 10 – how they felt in Norway (1 – in total isolation, 10 – fully engaged in the social life). As many as 31 % found themselves in the section between 1 and 4, which points to a relatively high level of social isolation. The most numerous section is that between 5 and 8 (59 %). Only 10 % declared their full engagement in social relations (the section between 9 and 10). There are several distinct reasons behind the social isolation of the immigrants. As many as 10 % admitted that they themselves had decided not to maintain any social contacts. 12 % experienced a cultural barrier which did not allow them to participate fully in Norwegian society. However, the language barrier, which prevents integration in a new society for obvious reasons, seems to be the most important (39 %). Some Poles (22 %) claimed to be treated unfairly or even discriminated against by Norwegians. The following forms of unfair treatment have been mentioned: „when I was trying to rent a flat; while I was driving, they were trying to overtake and kept giving me the finger and showing other taboo gestures, it was like letting me know who rules here, who the master is.; generally, Poles are not treated by Norwegians as equals, at the same time it must be said that 9 The table includes the results which were obtained by consolidating the following replies: frequently (very frequently + frequently), seldom (very seldom + seldom) .


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Norwegians are very kind towards immigrants; some get irritated when you don`t know the language; discrimination at work – they tried to make me quit the job, they bullied me, I had to be on sick leave for six months, find another job; obviously not a single Norwegian treated me as their equal despite all the high qualifications I hold; at work a Norwegian always ranks higher than a Pole irrespective of the skills and preparation for the job; my employer treated me unfairly when it comes to money; they looked down on me; they are racists who treat Poles as machines; in a designer shop a shop assistant treated me badly because she assumed I couldn`t afford things”. Surprisingly, 20 % of the informants declared that they were treated unfairly by other Poles. They gave several examples of such treatment: „ At work when they try to show off and prove that they are better and want to manage things; verbal abuse as a result of my positive outlook on life; having difficulties in retrieving the money I deserved for my work; showing contempt and superiority; insecurities; jealousy; I don`t want to have anything to do with the majority of other Poles abroad; they get on my nerves with practically everything they do; they refuse to accept my plans to settle down in Norway; discrimination at work because I do a painter`s job; they think they are superior just by the fact that they work here but, in fact, they have been and still remain brutes.” Only 7 % mentioned how they were treated badly by other foreigners (attempted fraud while shopping, vulgar behaviour, avoiding paying wages for illegal work).

4.4. Implications The health problems mentioned by the immigrants must be seen in the context of their hard work and stress resulting from their separation from the family. Several symptoms mentioned by the informants point to the phenomenon of culture shock, especially at the beginning of their stay abroad. The mental health symptoms are rather disturbing as they show that the immigrants live under constant stress. At the same time, they are unable to use the same coping strategies that they took advanatage of in similar emergency situations back in Poland. Seemingly, a good solution would be to meet a counsellor or a psychologist who speak Polish in order to learn how to manage stress. In an ideal case scenario, immigrants should be prepared to deal with immigration-related stress prior to their arrival in Norway. As regards the social dimension of health, the most alarming problem seems to be the feeling of social isolation. The best solution, often suggested by the immigrants themselves, would be the organisation of free Norwegian language courses. It would enable them to adapt to life in the Norwegian society better through more frequent and more direct encounters with Norwegian citizens. This would be beneficial because even though most migrants had come to Norway with an intention to earn enough money and then return to Poland, the research shows that the immigrants’ plans evolve as they prolong their stay in Norway.

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5. Immigrants’ use of the health care services in Norway “Increasing migration to and within Europe has confronted health care systems with the challenge of developing accessible, appropriate and effective services for migrants and ethnic minorities” (Ingleby, 2000) Although in most EU countries migrants are granted the same treatment as nationals when they obtain work and/or a residence permit, their access to health care systems is still problematic (Mladovsky). Equal access to health care is one of the main characteristics of equity in health (Oliver, Mossialos, 2004). Although Norway is not a member of the EU, it is a member of EEA (European Economic Area) so most of the EU legislation is implemented in the country. Migrants that have been granted work and a residence permit are entitled to the same medical treatments as Norwegians and also subject to the same cost-sharing regulations. Research on the health state of illegal immigrants is generally neglected. Illegal migrants have no rights to health care services in Norway, except for emergency services. The issue of immigrants’ use of health care services, often raised in literature, frequently refers to the existing barriers which limit their access to medical services. This theme has also been incorporated in the research under analysis. The following research problems have been formulated: • Do the Polish migrants use the health care services in Norway? • Where do they use them more often – in Poland or in Norway? Why? • What kind of barriers do they face in accessing the health care services in Norway?

5.1.

Use of health care services in Poland and in Norway

Because the cost of flights from Poland to Norway is relatively low, the immigrants often share their lives between the two countries. They perform some social roles in Poland, and others in Norway. Consequently, a question emerges: In which of the two countries do they function as a patient more frequently? 41 % of the surveyed migrants declared that they had used the health care services in Norway, mostly once or twice. They mainly visited a GP (66 %) but also mentioned emergency services, ear, nose and throat specialists, dentists, gynecologists, midwives, surgeons and opticians. Their reasons for using health care services were: pain (29 %), infection (26 %), worrying symptoms (26 %), accident at work (16 %), regular check-up (16 %), need of prescription drugs (16 %), chronic disease (11 %), need of sick leave (5 %). The migrants were asked where they used the health care services more often, in Poland or in Norway. Other research conducted so far suggests that Polish immigrants working in


25

Western countries often return to Poland to undergo medical treatment in private surgeries, thus contributing financially to the Polish medical institutions (Kawczynska-Butrym, 2009). In the current research, 61 % admitted going to the doctor’s more frequently in Poland, 10 % visited a physician in Norway more frequently than they used to in Poland and 29 % declared the same frequency of appointments with a doctor in both countries. The reasons for going to the doctor more often in Poland than in Norway is can be divided into six categories: – language (it is easier to communicate in your language, no language barrier), – cost (it is much cheaper, I don’t pay so much for a visit), – information (I know where to go, it is much easier), – accessibility (it is faster and more comfortable in Poland, medical services are more accessible in Poland), – trust (I trust my Polish doctors, I trust Polish doctors’ way of treatment, I know doctors in Poland), – lack of residence permit (Being here illegally , I`m a bit afraid . That`s the reason.) – other factors (I am usually sick when I go to Poland for holiday, I haven’t been sick in Norway so far.). The immigrants were also asked what kind of coping strategies they use in both countries when they did not feel well (table 9). Table 9. Coping strategies related to dealing with poor health Coping strategies

Poland (%)

Norway (%)

I go to see a doctor

50

18

I try to invent a treatment for myself

58

67

I ask my friends for advice

14

18

I wait until I recover

20

28

According to their declarations, only 18 % of the informants went to see a doctor in Norway when they did not feel well, whereas it was 50 % in Poland. What is interesting, the migrants’ preferred way of coping if they were not well was by treating the condition on their own. The country of living did not seem to influence that significantly. 43 % of the informants preferred to visit specialists in Poland, especially a dentist or gynecologist. The main reason for choosing dentists in Poland is the high cost of dental treatment in Norway. A theory of social distance helps explain why the female migrants prefer to seek help from a gynecologist in Poland rather than in Norway. These specialists has to “operate” in a very intimate environment, and it might be much more comfortable for women if their gynecologist comes from the same culture and speaks the same language. 29 % of the informants claimed that it does not matter if the doctor is Polish or Norwegian, as the quality of service is comparable. Interestingly, this opinion was expressed more frequently by the respondents who had used the Norwegian health care services before (p≥0.000). Nearly a fifth (17 %) agreed with the opinion that only a Polish doctor could

26


understand a Polish patient. 26 % considered access to the health care services in Poland to be better than in Norway, and 27 % were of the opposite opinion.

5.2. Obstacles limiting access to the health care services in Norway In general, the patient-related barriers (such as language barriers, beliefs concerning health and treatment, lack of trust in the health care system of the hosting country) and the systemrelated barriers (legislations, lack of information) can be distinguished. Mladovski mentioned three groups of factors that explain why even the legal migrants may experience unequal access to the health care: a) requirements for obtaining a permanent resident status can be very stringent, b) literacy, language and cultural differences, c) administrative and bureaucratic factors, lack of knowledge of the system and mistrust of health providers (Mladovsky). The research conducted among the Poles in Oslo showed that there are three main barriers in accessing the health care services by the Polish immigrants: lack of information, lack of language competence and economical factors. 5.2.1. Lack of information Most importantly, migrants, especially those from countries without a proper health care system, must learn how to get access to a “fastlege” (GP), who is the gatekeeper in the Norwegian health care system. All registered newcomers receive written information about the Norwegian “fastlegeordning” by post. Still, migrants usually do not understand this information because it is in Norwegian. The ones who have access to the Internet seem to be in a much better situation because they can find the information on the Norwegian health care system provided in many languages on the Norwegian Labour and Welfare Administration’s (NAV’s) website. According to their declarations, 59 % of the informants would like to get more facts about the health care services. The main sources of their information are friends (34 %), the internet (31 %), church (10 %) and trade unions (9 %). It seems like migrants do not use NAV or other similar institutions, which are the most competent sources of information. The fragment from a focused interview describes the kind of problems that migrants experience: „P1: Here we are more alert, you know an individual is sort of more alert, right. P2: But why? Alert to what? P1: Well, here you`re living under more stress. You have no family, you keep thinking about them all the time. You constantly think how to get by and get round things. P2: Here your thinking is adjusted in a somewhat different way, so to speak. P1: You keep thinking that you can`t afford to fall ill. P2; That`s another story. A sort of block. P1: Because you don`t know where to look for a doctor…. P2: When you fall ill, you find out. P3: We know nothing about the health care system, nothing about where to go for help...


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P2: But you have this doctor assigned to you by NAV, don`t you? P3: That too, but it`s more about what this appointment should be like, whether you need to pay something and some other detailed info. From what I hear, you have to book an appointment in advance and wait for about two-three days. P2: You have to wait until you get better and then you can see the doctor.“ Another immigrant, a construction worker, aged 52, admits: ”Health? I always try to tend to it, but obviously here in Norway it`s kind of blurred. They have a different approach to these health care services. In Poland everyone has a medical centre, a family doctor and here it`s far less clear. Well, you get assigned some kind of area, some sort of a medical centre once you get your personal ID number. But I haven`t used it yet.” The immigrants possess rudimentary knowledge of the GP scheme and as a result are not certain how to use the health care services. Additionally, some immigrants do not have computers at home and are not familiar with the Internet. Even if they receive information from NAV by post, they still do not have access to it because they do not understand Norwegian (“For us the language is a real barrier…”). 5.2.2. Foreign language incompetence Language issues present significant barriers to many immigrants. Those who speak neither English nor Norwegian may have basic practical problems with accessing the health care services (making appointments, communicating with a doctor). According to IMDI’s research, many migrants speak little or no Norwegian even after a few years` stay in Norway (IMDI, 2008). Professional translators should be available and, more importantly, the immigrants must be informed about their right to have one. The population-based study conducted among immigrants in Sweden showed that their knowledge of language was related to their selfreported health status and their use of the healthcare services (Wiking et al., 2004). In a study conducted in England and Wales, language and communication difficulties appeared to be very important issues affecting the migrant worker’s health and safety (Mc Key et al., 2006). According to the present research, 29 % of the Polish immigrants did not speak English, 39 % did not speak Norwegian and 12 % spoke neither English nor Norwegian. They felt discriminated against because of the language: “I was rejected when I spoke English. They demanded I speak Norwegian although I didn’t understand a word.” “Some of them (Norwegians) get irritated If I don’t speak Norwegian. If you don’t speak a very good Norwegian they treat you worse at work, in a pub and in public offices” “ You have to be like the Norwegians in order to be accepted in the society. I am Polish and I think in Polish”. There is a strong correlation between language abilities and the immigrants’ future plans. Those who did not speak Norwegian were more likely to plan their return to Poland (p